Spinal Needle Stylet Hokey Pokey

Spinal Needle StyletCertainly, one of the most common procedures in the Ped ED is the lumbar puncture.  We have discussed efforts to ensure that our first attempt is our best attemptgood positioning and analgesia are critical.  We have also discussed how to deal with the result when the LP was traumatic.  Additionally, we have covered the complication of Post-LP Headaches. One question we should ask though is… are we undermining our own success rate?  Do we need to keep replacing the Spinal Needle Stylet? Does playing the LP Hokey Pokey help or hurt us?


Anatomy Matters

  • One major goal of the Lumbar puncture is to obtain an atraumatic tap (AKA “Champagne Tap”)
    • An aside – What “Champagne tap” means is often debated
      • Does it just reference Zero RBCs, or does it also have to have No leukocytes?
      • Is it for every LP you do? Or just the first time you do one? 
      • Who is to say?  Generally the person buying the bottle of champagne is the one to make “the rules.”
    • Having an atraumatic tap will make interpretation and management more clear. (Clear fluid => clear decisions)
    • See Traumatic Tap Morsel for reasons why you should NOT adjust your CSF results in an attempt to interpret CSF with lots of RBCs.
  • Landmarks: [Bonadio, 2014]
    • Superior Iliac Crest
    • Supracristal line
      • Horizontal line connecting superior portion of superior iliac crests.
      • Intersects the spinal column at the L3-L4 interspace.
    • Whether in the lateral decubitus position or the seated position (See Morsel as to why you may want to favor the seated position), ensure the spinal column and the supracristal line are perpendicular to each other.
  • Spinal Cord terminates around level of L1.
  • Venous plexus
    • Surrounds the dura lining.
    • Ventral to the subarachnoid space the plexus is extensive.
    • Important not to “over-shoot” the subarachnoid space as you will likely encounter the extensive venous plexus that is ventral to it. [Bonadio, 2014]
    • Using a stylet can cause you to inadvertently over-shoot, as you blindly advance the needle and may advance through the lumbar cistern and enter the venous plexus that is ventral to it.


Spinal Needle Stylet: Why Use It?

If using a stylet may make it more likely to have a traumatic LP, then why use it at all?

  • There are cases of intraspinal epidermoid tumors arising related to LPs. [Ziv, 2004]
  • The hollow tip of a needle can, potentially, carve out a plug of epidermis or dermis and then translocate that into the subarachnoid space.
  • The stylet converts a hollow bore needle into a solid one, thus, preventing a plug of skin being carved out and transplanted.


Spinal Needle Stylet: Not a Dance

  • Obviously, if we want to avoid creating a complication like epidermoid tumors, we need to use the spinal needle stylet; however, this often has lead to an interesting dance:
    • Inserting the stylet, advancing the needle, removing the stylet, checking for CSF, reinserting the stylet, advancing again, and repeating
    • “You put the stylet in. You put the stylet out. You put the stylet in and … you hope you get CSF and not blood” (ok, not the best dance song).
  • Two main issues exist with the “Stylet Hokey Pokey:”
    • 1st – The “pop” sensation of piercing the inner ligaments is not as prominent in children as adults, so having the stylet in position can lead to over-inserting the needle and entering the ventral venous plexus… and turning champagne into fruit punch.
    • 2nd – The stylet is, itself, sharp. Repeatedly reinserting it also increases the potential for inadvertently sticking your self with it.


Spinal Needle Stylet: Best of Both Worlds

  • There is a way to both minimize the risk of causing epidermoid tumor AND minimize risk of a traumatic LP. [Bonadio, 2014; Baxter, 2006; Strupp, 1997]
    • Appropriately position the child and ensuring adequate analgesia and sterile prep.
    • Insert the spinal needle through the epidermis and dermis with the stylet in place.
    • Once through the dermal layers (< 1cm), remove the stylet and advance slowly without the stylet.
    • Stop once CSF is seen to flow into the hub of the spinal needle.
    • Rejoice.
  • The stylet should be reinserted prior to removing the spinal needle completely to help minimize post-LP headaches.



Bonadio W1. Pediatric lumbar puncture and cerebrospinal fluid analysis. J Emerg Med. 2014 Jan;46(1):141-50. PMID: 24188604. [PubMed] [Read by QxMD]

Baxter AL1, Fisher RG, Burke BL, Goldblatt SS, Isaacman DJ, Lawson ML. Local anesthetic and stylet styles: factors associated with resident lumbar puncture success. Pediatrics. 2006 Mar;117(3):876-81. PMID: 16510670. [PubMed] [Read by QxMD]

Ziv ET1, Gordon McComb J, Krieger MD, Skaggs DL. Iatrogenic intraspinal epidermoid tumor: two cases and a review of the literature. Spine (Phila Pa 1976). 2004 Jan 1;29(1):E15-8. PMID: 14699293. [PubMed] [Read by QxMD]

Strupp M, Brandt T. Should one reinsert the stylet during lumbar puncture? N Engl J Med. 1997 Apr 17;336(16):1190. PMID: 9102578. [PubMed] [Read by QxMD]
Bonadio WA1, Smith DS, Goddard S, Burroughs J, Khaja G. Distinguishing cerebrospinal fluid abnormalities in children with bacterial meningitis and traumatic lumbar puncture. J Infect Dis. 1990 Jul;162(1):251-4. PMID: 2355199. [PubMed] [Read by QxMD]

Bonadio WA, Smith DS, Metrou M, Dewitz B. Estimating lumbar-puncture depth in children. N Engl J Med. 1988 Oct 6;319(14):952-3. PMID: 3419463. [PubMed] [Read by QxMD]
Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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  1. […] Success rates in infant lumbar punctures may be declining as we do fewer and fewer (doing fewer is a good thing, except that we get less experience). One thing that can improve success is early stylet removal. The stylet is kept in when entering the skin in order to avoid the very rare complication of intraspinal epidermoid tumors. However, once the needle is past the epidermis and dermis, such that a plug of skin tissue cannot be cored out by the hollow needle and deposited into the spinal canal, the stylet can be removed. Here are two excellent FOAMed discussions of this practice and the advantages: http://pemcincinnati.com/blog/wwdwwd-early-stylet-removal-lp/ and https://pedemmorsels.com/spinal-needle-stylet/ […]

  2. Sean,
    How’s it going? Hope that you’re well, as always!

    Just wanted to let you know that all of my residents are loving the Morsels – we just went over the “stylet v no stylet” thing for LP, and everyone found it super-helpful. You’re the man!


    • THANK YOU, Dr. Walsh!
      Things are going well in the land of PedEMMorsels… especially since you and your residents are finding them useful!

      Thank you,

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